International Journal of Infectious Diseases 30 (2015) e98–e105
Contents lists available at ScienceDirect
International Journal of Infectious Diseases journal homepage: www.elsevier.com/locate/ijid
Gender-related differences in outcomes and attrition on antiretroviral treatment among an HIV-infected patient cohort in Zimbabwe: 2007–2010 Kudakwashe C. Takarinda a,b,*, Anthony D. Harries b,c, Ray W. Shiraishi d, Tsitsi Mutasa-Apollo a, Abu Abdul-Quader d, Owen Mugurungi a a
AIDS and TB Unit, Ministry of Health and Child Care, PO Box CY 1122, Causeway, Harare, Zimbabwe International Union Against Tuberculosis and Lung Disease, Paris, France c Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK d Division of Global HIV/AIDS, Center for Global Health, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA b
A R T I C L E I N F O
Article history: Received 6 January 2014 Received in revised form 7 October 2014 Accepted 10 November 2014 Keywords: Antiretroviral therapy Attrition Zimbabwe Gender differences HIV mortality
S U M M A R Y
Objectives: To determine (1) gender-related differences in antiretroviral therapy (ART) outcomes, and (2) gender-specific characteristics associated with attrition. Methods: This was a retrospective patient record review of 3919 HIV-infected patients aged 15 years who initiated ART between 2007 and 2009 in 40 randomly selected ART facilities countrywide. Results: Compared to females, males had more documented active tuberculosis (12% vs. 9%; p < 0.02) and a lower median CD4 cell count (117 cells/ml vs. 143 cells/ml; p < 0.001) at ART initiation. Males had a higher risk of attrition (adjusted hazard ratio (AHR) 1.28, 95% confidence interval (CI) 1.10–1.49) and mortality (AHR 1.56, 95% CI 1.10–2.20). Factors associated with attrition for both sexes were lower baseline weight (60 kg), initiating ART at an urban health facility, and care at central/provincial or district/mission hospitals vs. primary healthcare facilities. Conclusions: Our findings show that males presented late for ART initiation compared to females. Similar to other studies, males had higher patient attrition and mortality compared to females and this may be attributed in part to late presentation for HIV treatment and care. These observations highlight the need to encourage early HIV testing and enrolment into HIV treatment and care, and eventually patient retention on ART, particularly amongst men. ß 2014 The Authors. Published by Elsevier Ltd on behalf of International Society for Infectious Diseases. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/bync-nd/3.0/).
1. Introduction With only 12% of the world’s population, Sub-Saharan Africa has 68% of the world’s burden of HIV/AIDS cases.1 Zimbabwe, a country in southern Africa, is also badly affected by the HIV/AIDS epidemic, with recent statistics showing an HIV prevalence of 15% in the 15–49 years age group according to the 2010–2011 Zimbabwe Demographic and Health Survey.2 Since the national antiretroviral treatment (ART) programme was initiated in 2004, there has been a continuous increase in the cohort of HIV-infected individuals accessing this life-saving
* Corresponding author. Tel.: +263 4 2933495. E-mail address: [email protected] (K.C. Takarinda).
intervention in Zimbabwe. The number of health facilities offering ART services increased from 7 in 2004 to 960 by December 2012,3 and those receiving ART increased from 24 500 people in 2005 to 531 136 by the end of 2012.3 In terms of adult ART coverage, the country reached universal access levels of 85% in 2012, but with changing global guidelines, which recommended earlier ART initiation, the coverage dropped to 53% in December 2013.4 Despite this continued scale-up in numbers of HIV-infected patients receiving ART, a growing concern in most ART programmes is patient retention in care, which is critical for the success of such programmes. A meta-analysis of 32 ART programs in Africa, excluding Zimbabwe, showed that retention was 60%, with loss to follow-up being the major cause of attrition, followed by death.5 Partly associated with attrition from HIV treatment and care is male gender,6–11 and this has been attributed in part to
http://dx.doi.org/10.1016/j.ijid.2014.11.009 1201-9712/ß 2014 The Authors. Published by Elsevier Ltd on behalf of International Society for Infectious Diseases. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).
K.C. Takarinda et al. / International Journal of Infectious Diseases 30 (2015) e98–e105
advanced HIV disease at the time of ART initiation7,12 and poor treatment adherence among males.11,13 Despite knowing that attrition is higher among males, little is known about differences in the immunological response to ART between males and females in the routine ART programme setting. Furthermore, few studies have assessed the factors specific to males and females that influence attrition from ART. Identifying these gender-specific attritionassociated factors is critical for determining priority areas for improving patient retention for each sex. In Zimbabwe, a review of the national ART programme revealed that patient retention rates at 36 months was 64.4% and that male gender increased the risk of attrition.14 Using this dataset we conducted an extended data analysis aimed at determining: (1) gender-related differences in ART outcomes, primarily attrition from treatment, mortality, loss to follow-up, and immunological failure, and (2) gender-specific characteristics associated with attrition. 2. Methods 2.1. Study design We conducted a retrospective cohort study using routinely collected ART programme data. 2.2. Setting: general and site-specific 2.2.1. Clinical procedures in the Zimbabwe National ART Programme ART eligibility between 2007 and 2009 was based on national guidelines15 adapted from the World Health Organization (WHO):16 ART was initiated in patients with a documented HIVpositive test who were classified with WHO clinical stage 3 disease and a CD4+ cell count 90 days after the last scheduled appointment with the healthcare provider or pharmacy, whilst defaulters were those who had not come back to the clinic for
Contents lists available at ScienceDirect
International Journal of Infectious Diseases journal homepage: www.elsevier.com/locate/ijid
Gender-related differences in outcomes and attrition on antiretroviral treatment among an HIV-infected patient cohort in Zimbabwe: 2007–2010 Kudakwashe C. Takarinda a,b,*, Anthony D. Harries b,c, Ray W. Shiraishi d, Tsitsi Mutasa-Apollo a, Abu Abdul-Quader d, Owen Mugurungi a a
AIDS and TB Unit, Ministry of Health and Child Care, PO Box CY 1122, Causeway, Harare, Zimbabwe International Union Against Tuberculosis and Lung Disease, Paris, France c Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK d Division of Global HIV/AIDS, Center for Global Health, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA b
A R T I C L E I N F O
Article history: Received 6 January 2014 Received in revised form 7 October 2014 Accepted 10 November 2014 Keywords: Antiretroviral therapy Attrition Zimbabwe Gender differences HIV mortality
S U M M A R Y
Objectives: To determine (1) gender-related differences in antiretroviral therapy (ART) outcomes, and (2) gender-specific characteristics associated with attrition. Methods: This was a retrospective patient record review of 3919 HIV-infected patients aged 15 years who initiated ART between 2007 and 2009 in 40 randomly selected ART facilities countrywide. Results: Compared to females, males had more documented active tuberculosis (12% vs. 9%; p < 0.02) and a lower median CD4 cell count (117 cells/ml vs. 143 cells/ml; p < 0.001) at ART initiation. Males had a higher risk of attrition (adjusted hazard ratio (AHR) 1.28, 95% confidence interval (CI) 1.10–1.49) and mortality (AHR 1.56, 95% CI 1.10–2.20). Factors associated with attrition for both sexes were lower baseline weight (60 kg), initiating ART at an urban health facility, and care at central/provincial or district/mission hospitals vs. primary healthcare facilities. Conclusions: Our findings show that males presented late for ART initiation compared to females. Similar to other studies, males had higher patient attrition and mortality compared to females and this may be attributed in part to late presentation for HIV treatment and care. These observations highlight the need to encourage early HIV testing and enrolment into HIV treatment and care, and eventually patient retention on ART, particularly amongst men. ß 2014 The Authors. Published by Elsevier Ltd on behalf of International Society for Infectious Diseases. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/bync-nd/3.0/).
1. Introduction With only 12% of the world’s population, Sub-Saharan Africa has 68% of the world’s burden of HIV/AIDS cases.1 Zimbabwe, a country in southern Africa, is also badly affected by the HIV/AIDS epidemic, with recent statistics showing an HIV prevalence of 15% in the 15–49 years age group according to the 2010–2011 Zimbabwe Demographic and Health Survey.2 Since the national antiretroviral treatment (ART) programme was initiated in 2004, there has been a continuous increase in the cohort of HIV-infected individuals accessing this life-saving
* Corresponding author. Tel.: +263 4 2933495. E-mail address: [email protected] (K.C. Takarinda).
intervention in Zimbabwe. The number of health facilities offering ART services increased from 7 in 2004 to 960 by December 2012,3 and those receiving ART increased from 24 500 people in 2005 to 531 136 by the end of 2012.3 In terms of adult ART coverage, the country reached universal access levels of 85% in 2012, but with changing global guidelines, which recommended earlier ART initiation, the coverage dropped to 53% in December 2013.4 Despite this continued scale-up in numbers of HIV-infected patients receiving ART, a growing concern in most ART programmes is patient retention in care, which is critical for the success of such programmes. A meta-analysis of 32 ART programs in Africa, excluding Zimbabwe, showed that retention was 60%, with loss to follow-up being the major cause of attrition, followed by death.5 Partly associated with attrition from HIV treatment and care is male gender,6–11 and this has been attributed in part to
http://dx.doi.org/10.1016/j.ijid.2014.11.009 1201-9712/ß 2014 The Authors. Published by Elsevier Ltd on behalf of International Society for Infectious Diseases. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).
K.C. Takarinda et al. / International Journal of Infectious Diseases 30 (2015) e98–e105
advanced HIV disease at the time of ART initiation7,12 and poor treatment adherence among males.11,13 Despite knowing that attrition is higher among males, little is known about differences in the immunological response to ART between males and females in the routine ART programme setting. Furthermore, few studies have assessed the factors specific to males and females that influence attrition from ART. Identifying these gender-specific attritionassociated factors is critical for determining priority areas for improving patient retention for each sex. In Zimbabwe, a review of the national ART programme revealed that patient retention rates at 36 months was 64.4% and that male gender increased the risk of attrition.14 Using this dataset we conducted an extended data analysis aimed at determining: (1) gender-related differences in ART outcomes, primarily attrition from treatment, mortality, loss to follow-up, and immunological failure, and (2) gender-specific characteristics associated with attrition. 2. Methods 2.1. Study design We conducted a retrospective cohort study using routinely collected ART programme data. 2.2. Setting: general and site-specific 2.2.1. Clinical procedures in the Zimbabwe National ART Programme ART eligibility between 2007 and 2009 was based on national guidelines15 adapted from the World Health Organization (WHO):16 ART was initiated in patients with a documented HIVpositive test who were classified with WHO clinical stage 3 disease and a CD4+ cell count 90 days after the last scheduled appointment with the healthcare provider or pharmacy, whilst defaulters were those who had not come back to the clinic for
